Bringing the whole university to Ethiopia

The story of the University of Wisconsin-Madison’s expanding web of global health initiatives in Ethiopia began with one man’s homecoming. Dr. Girma Tefera, a professor in the Department of Surgery in the School of Medicine and Public Health, spent 14 years without visiting his family in the southern Ethiopian highlands, studying medicine in Italy and Germany and establishing his career in vascular medicine at UW-Madison. The oldest of seven children, he lost his father while young. Although his mother did not have the chance to go to school, all of her children became professionals. Only Tefera went abroad.

When Tefera returned to visit friends, family and familiar landscapes in 2000, he was struck by a sense of belonging and a desire to do something about the challenges he saw. He realized it was time to transform his success into something that would help his homeland. He volunteered to help with surgeries in and soon began recruiting UW-Madison colleagues to partner with Addis Ababa University (AAU). The resulting partnerships are changing the face of Ethiopian health care.

Concern for his homeland led Dr. Girma Tefera, professor of vascular surgery, left, to begin volunteering in Ethiopia. Dr. Cynthia Haq, professor of family medicine, was an early collaborator and founding director of UW-Madison’s Center for Global Health.

Tefera built bridges that are a strong foundation for expanding UW-Madison’s engagement and developing a global health care model that can be used in other countries with few resources, says Dr. Jonathan Patz, director of the UW-Madison Global Health Institute (GHI). Located mostly in the horn of East Africa, Ethiopia is home to more than 90 million people and encompasses the complex, interconnected challenges that face many resource-challenged nations. Rapid population growth, urbanization and development provide challenges and opportunities for UW-Madison to collaborate with Ethiopian partners to chart a course for sustainable health. “I’d like to bring the whole university to Ethiopia,” says Patz, an environmental public health scientist and also professor in the Nelson Institute and the Department of Population Health Sciences. “UW-Madison is an incredible one-stop shop with expertise across all fields on one campus. … If we’re truly going to take meaningful steps toward solving root problems, we need to pursue a concerted, multi-perspective approach.” Local collaborators provide a critical part of that multi-perspective approach, and Patz looks for a bidirectional flow of information.

“Only they who are on the ground, living the challenges and understanding what really goes on in their location will have any kind of clue of how we might be able to help”—Dr. Jonathan Patz

“In many resource-constrained areas, they’ve lots of lessons to teach us about innovation under those extreme conditions. We will learn as much or more from them as they will learn from us.” The Ethiopian projects are grounded in GHI’s “global health ethic” that champions health for today without compromising resources for tomorrow. This responsibility is grounded in justice, collaboration and eco-integrity and brings together faculty, staff and students from across campus to address the health implications of climate change, urban design, air quality, water safety, food security and access to care. “We can take a leading role in this country and achieve great outcomes,” Patz says. “We’re really trying to knit this together to have a comprehensive approach to disease prevention in Africa.” In 2011, Ethiopian President Girma Wolde Giorgis awarded UW-Madison a Certificate of Recognition for its “advancement of knowledge, action and practice in the fight against ill health and for the voluntary service of the people of Ethiopia.”

Everything is health

“Everything is health,” says Tefera, who welcomes the expanding UW collaborations in his homeland. “Health is not only giving medicines and vaccines; people also need to be able to eat right. You need clean water and clean air to breathe. The list is fairly long. … That’s why everybody needs to chip in.” The need is great in a country where 82 percent of the 93 million people are rural, mostly living on farms only big enough to feed their families. On average, Ethiopians earn $1,110 a year. The probability of dying before the age of 5 years is 10 times higher than in the United States, and the maternal mortality rate is one of the highest in the world. Developed countries account for only a small fraction of the world’s population, and it’s time to come up with solutions that impact the rest, Tefera says. “There are things we may end up learning by being there,” he adds. “It’s all about resources.”

There’s no better place to learn than a low-resource place. There’s no place to be more creative.—Dr. Girma Tefera

When UW-Madison faculty, staff and students working in Ethiopia met to discuss their projects, participants arrived from schools and colleges including Agricultural and Life Sciences, Engineering, Medicine and Public Health, Pharmacy, and the Nelson Institute. Their projects are a snapshot of how UW-Madison partnerships are addressing immediate health needs and the causes of disease: Monitoring urban air pollution and developing rural biogas energy production Improving medical education and medical and preventive care, from emergency medicine and family practice to pediatric infectious disease, obstetrics and gynecology Tackling road safety and designing healthy cities with alternative transportation Finding ways to maximize hydropower, limit mosquito breeding sites that can promote malaria and provide water for electric power and for irrigation Introducing sweet potatoes and helping farmers adapt to climate change “Every developing country needs decent health care,” Patz says. With a core of clinical and preventive services, an effective health effort must also encompass food and water security and environmental safety. “If we’re serious about pursuing a “global health ethic,” we are required to have this integrated, broader approach to global health problems,” Patz says.

Air pollution, healthy cities, bicycles

“Everything I do is related to either human health or climate change, which are intertwined,” says James Schauer, professor of civil and environmental engineering and an international expert in the chemistry of air pollution.

“We don’t like air pollution,” Schauer says. “We don’t like the way it looks, and we don’t like it in our cities. However, the reality is that the reason we’re going to do something about air pollution is because of human health.”—Professor Jamie Schauer

This year, Schauer is setting up air quality monitoring equipment in Addis Ababa to learn where pollution comes from, its effect on humans and what can be done about it. To Schauer, Addis is like Beijing, China, in 1990, before the population exploded and the air turned brown. “I see this as an opportunity to connect with people at early stages of development,” he says. “When you have real data about air pollution, which quantifies the concentrations and composition, compares the data to the World Health Organization standards and concentrations in other countries, then this provides a baseline to really make changes in the future trajectory of air pollution instead of just talking about the problem.”

People, animals and motorized vehicles share Ethiopian highways.

Highways are narrow and crowded.

Carts are a common site.

Three-wheeled bajas are crowding out bicyclists.

Small trucks race along highways to bring goods to market.

Bicyclists also compete for room to ride.

Patz and his team, including doctoral student Selam Zewdie and Jason Vargo, an assistant scientist in the Global Health and Nelson institutes, also hope to limit pollution and improve health as they champion bicycle and walking-friendly cities. Their focus is on Hawassa and Bahir Dar ̶ cities like Madison with lakes, universities and walking paths ̶ that are on a fast-track for exponential growth. By 2050, Ethiopia’s urbanized population is expected to double to 35 percent, and the smaller cities that will accommodate the bulk of that growth have the opportunity to design sustainable, livable neighborhoods, says Vargo, who recently accompanied Patz to visit with local and national officials and university presidents about healthy urban design.

“They haven’t built the infrastructure yet; it’s a golden opportunity to do it right the first time.”—Assistant Scientist Jason Vargo

Growing up in Hawassa, Zewdie watched professional men and women ride bicycles to work. Because she rode a bike, Ethiopians knew she had to be from Hawassa or Bahir Dar, the only two cities where girls learned to ride, giving women unusual mobility. Growth, automobiles and the ubiquitous “bajajs,” or motorized rickshaws, are rapidly crowding out bicyclists, and Zewdie’s first project will involve reintroducing bicycles at Hawassa University. “Not only is (sustainability) possible, it’s a must,” Zewdie says. “The city is where most of us are going to reside, eventually, throughout the world. We see it as the best place to have these interventions come in before there’s a problem. … We know that’s the only way going forward.” Vargo is finding ways to model the health implications of urbanization and sees opportunities to educate Ethiopian planners who will look at urban design to benefit health. “Ethiopia is a harbinger for the rest of the world,” he says. “What do you want it to look like 50 years from now? What do you need to do now?”

Doctoral student Selam Zewdie, left, watched men and women ride their bikes to work when she was growing up in Ethiopia. She’s collaborating now to reintroduce bicycles at Hawassa University.

Patz will be asking those questions when he spends a portion of his 2014-2015 sabbatical in Ethiopia, under a recently announced Fulbright Scholar Award. He will collaborate with faculty and policy makers working on Ethiopia’s “Climate Resilient Green Economy” agenda. He plans to dovetail that experience with work at the World Health Organization (WHO), the University of Geneva and Graduate Institute of International and Development Studies, preparing for the major United Nations climate change negotiations in 2015. He’s inspired by Ethiopia’s national commitment to climate change and an environmentally sustainable economy. Addis Ababa, the capital, is also the seat of the African Union. “What happens in Addis Ababa and Ethiopia can diffuse to the rest of the continent,” he says.

Roads, water and malaria

Traffic engineer Rahel Desalegne, who also grew up in Ethiopia and is married to Tefera, dreams of an Ethiopian culture of road safety where drivers follow traffic rules and do not drink and drive, and engineers have sound principles for road design. Her task is clear in a country where bicycles, cars, horses and carriages, people, busses and livestock share roads and small trucks race along two-lane highways bringing fresh produce to the cities. “They have to go fast,” Desalegne says. “It’s their livelihoods.” Road traffic injuries are the eighth leading cause of death globally and the leading cause of death for young people ages 15 to 29, according to the 2013 WHO Global Status Report on Road Safety. WHO projects road injuries will be the world’s fifth most common cause of death by 2030, disproportionately affecting developing countries, says Desalegne, who founded a non-governmental organization to collaborate with UW-Madison and Ethiopian engineers and policy makers to find solutions. “At the end of the day, you want to do something impactful,” she says. “I’m just a drop in the sea. Living here, being educated here, I can go back and share that and make a difference.”

UW-Madison faculty and staff are collaborating with partners across Ethiopia.

Water resources bring Paul Block, an assistant professor of civil and environmental engineering, to the health discussion. “I’m water-centric,” he says. “It’s not too hard to draw connections between water quantity, water quality and health.” He’s looking at the best ways to maximize hydropower yet also limit mosquito breeding and the resulting malaria outbreaks, while providing water for farms in northern Ethiopia. Reliable electricity could improve health and education, he says. Farmers who drill wells might be able to irrigate a second crop, adding to their income.

Heidi Busse, an associate researcher in the School of Medicine and Public Health, manages a partnership with the International Potato Center to improve the food security and resilience of 30,000 small farmers. The project looks to increase the production and consumption of orange-fleshed sweet potatoes, which have a higher nutritional value than white potatoes. The university is looking at the impact of the integrated and health program on individuals, households and the environment, Busse says.

Jeremy Foltz, a professor of agricultural and applied economics, studies how farmers on Ethiopia’s Choke Mountain will respond to climate change. He also has graduate students looking at how extreme heat and heavier rains will affect infant and child mortality as malaria-bearing mosquitoes move into the highlands and families have only mud houses with tin roofs as shelter from rising temperatures.

A small reservoir provides drinking water amid the agricultural fields in Koraro, Ethiopia. Assistant professor Paul Block is helping maximize hydropower while minimizing the spread of malaria and providing water for agriculture.

Paul Block spent time with local youth while working in northwestern Ethiopia.

These are big issues with a lot of intellectual moving parts,” says Foltz, who appreciates the breadth of knowledge at UW-Madison. As an economist, for example, he looks to Mutlu Ozdogan, associate professor of forest ecology and environmental studies, for climate information that informs his study of how farmers will adapt to climate change. “There are a lot of health issues that cross a lot of boundaries,” he says.

“What’s important is the ability to be able to access other bits of knowledge on this campus and do joint projects. The promise of GHI is to bring everybody in. There are a lot of health issues that cross many boundaries.” — Jeremy Folz

A history of better health

In 2009, UW-Madison’s commitment to Ethiopia deepened when the American International Health Alliance chose Tefera and colleagues to establish the UW-Madison/AAU HIV/AIDS Twinning Center program. The partnership, based on peer-to-peer decision-making and long-term relationships was designed to strengthen the country’s emergency medical services through education and by building capacity for research and patient care. It was the first of several grants supporting UW/AAU initiatives, and the results have been far-reaching:

The Emergency Medicine Training Center has trained more than 4,200 urban and rural medical professionals to work throughout the country.

Residency programs in emergency medicine and family medicine and a master’s in nursing in emergency medicine are giving Ethiopian clinicians better ways to care for patients. Fellowship trainings have been developed for providers in pediatric emergency medicine, pulmonary and critical care, and trauma and surgical care.

Quality improvement (QI) training helped Addis Ababa’s Black Lion Hospital develop a triage system, ensuring the most critically ill patients are seen first. With QI, infection control compliance at Black Lion jumped from 30 percent to more than 80 percent as staff established routines for tasks such as managing trash, using sterile needles, washing hands and using gloves.

Medical partnerships are expanding to Hawassa University, where Dr. Cynthia Anderson, a clinical assistant professor of obstetrics, leads efforts to establish an obstetrics/gynecology residency. “Hawassa is located in rural southern Ethiopia, where the density of healthcare providers is extremely low and the needs of the population extremely high, especially related to maternal and child health,” Anderson says. Hawassa University’s Medical School has just launched its’ first ever OB/GYN residency training program, and OB/GYN department chair Dr. Zenebe Wolde and residency program director Dr. Million Teshome, newly-appointed Residency Program Director, visited UW-Madison in May, 2014 to learn about resources the university has to offer, build clinical skills and generate ideas about how to strengthen their department.

UW-Madison joined the Medical Education Partnership Initiative (MEPI), a U.S. Department of Health and Human Services and Fogarty International Center program, to strengthen medical education, provide faculty development and stimulate research. It is led by faculty at AAU and includes four Ethiopian and four U.S. universities. UW-Madison is taking the lead to support family medicine, gender equity and faculty mentoring programs.

After completing faculty development fellowships in Madison, eight AAU physicians worked with faculty from UW-Madison and the University of Toronto to launch the first family medicine residency training program in Ethiopia.

Seven Ethiopian women faculty members completed faculty development fellowships at UW-Madison. They are now leading efforts to promote gender equity in medical education. One of the first fellows, Dr. Mahlet Gebremariam, was named Dean of the AAU School of Medicine. She is the only woman dean of a medical school in the country.

Dr. Cynthia Anderson, clinical professor of obstetrics, right, visits Hawassa University, where she is leading efforts to establish an obstetrics/gynecology program. (Photo by Nicholas Schmul.)

“As colleagues committed to outstanding women’s health care and education across cadres of health care workers, we hope to build curriculum and create student and faculty exchange that will expand the educational reach of both institutions into our communities and beyond,” Anderson said. “As a doctor, I am drawn to work where the needs are greatest,” says Dr. Cynthia Haq, professor of family medicine, founding director of the UW-Madison Center for Global Health and an early collaborator who’s seen remarkable progress. Now, due to the efforts of Ethiopian physicians who completed fellowships at UW-Madison and UW visiting faculty, most children admitted to the Addis Ababa emergency room survive, she says. The UW-led Advanced Life Support in Obstetrics training has been so successful that the Ministry of Health is adding it to training for EMTs across the country. With its new family medicine residency program, the government hopes to train 1,000 primary care physicians who will be deployed to health centers and district hospitals to supervise health extension workers. AAU faculty members also have developed new policies to promote a gender-friendly learning environment. “It’s not just about us helping Ethiopia,” Haq adds.

“We’re learning from our Ethiopian colleagues about how to do more with less and how to integrate medicine, public health and sustainable development. This work is opening the eyes of students and faculty as we become world citizens.” —Dr. Cynthia Haq